Abstract
Cost control choices for the Affordable Care Act are a logical topic for this special issue because of both the policy and political importance of the choices and what they illustrate about the use of policy analysis in policy making. This article argues that the common trope that research-based evidence is ignored because of “politics” misunderstands the patterns of policy analysis. Politicians did listen to interest groups, voters, and their own attitudes, but the visibility and credentials of different policy analyses were also important. The advice structure and validation of ideas for budgetary decisions also differed distinctly from that for choices about how to control overall health care spending. This article illustrates patterns of influence with regard to three types of cost controls: price regulation, limits on insurance, and an aspirational agenda of system reengineering measures such as accountable care organizations, pay for performance, and cost-effectiveness analysis. Even the meaning of evidence for some measures (e.g., reengineering) was different from that for others (e.g., price regulation). Being heavily promoted by the most prestigious policy experts did not mean ideas were either well supported by evidence or politically safe. The question may be more why politicians listened to some analysts than why they do not listen to analysis.
